VP, Payment Integrity

Job Description

Job Summary

The VP, Payment Integrity position provides strategic leadership, vision, and expertise in support of the cross-functional Payment Integrity organization. It is focused on driving efficiencies, identifying new concept opportunities, and technology enablement to meet goals, minimize administrative expense, and improve performance.

Job Duties

• Lead Molina’s Payment Integrity Content Ideation, Research and Edit Development teams in support of the cross-functional Payment Integrity organization.

• Responsible for concept identification and validation & root cause analysis team to drive content optimization/minimize dispute overturn rates.

• Provides leadership, management, and vision necessary to maximize accurate overpayment recovery while driving prevention efforts and Cost of Care savings.

• Provides strategic leadership for both pre-pay and post-pay programs to grow overpayment identification coverage, drive recovery results, and manage administrative costs.

• Under the general direction of the SVP Payment Integrity, this role provides input for the strategy, design, and implementation of payment accuracy initiatives impacting core claims operations.

• Determines strategy for outsourcing, technology enablement and process efficiencies to effectively meet goals and minimize administrative expense.

• Ensures the achievement of financial objectives and operational excellence.

• Identifies technical improvement needs to expand concept ideation: connection with new databases, report monitoring, BOTs/Automation, etc.

• Meets with Health Plan or Shared Service leadership to identify new concept opportunities and translates business requirements to the technical team to determine viability.

• Analyze SLA parameters with team performance and planning continuous improvement in performance, process optimization, adherence to reporting schedules and maintaining all necessary process documentation as per the process protocol.

• Participates in monthly business review meeting with executive leadership team, business stakeholders and ensures the resolution of all issues to the satisfaction of Molina’s local Health Plan business partners.

Other duties which are of secondary importance to the positions purpose:

• Claims Adjudication accuracy including configuration in QNXT (i.e. Claims Production, Audit, Production Vendor Oversight) for all lines of business. Claims Shared Services for all lines of business, i.e., activities supporting the production of claims including but not limited to the Corporate Recovery Team, Corporate Claims Compliance Team, Support Services, Enrollment and Billing, Corporate Encounter Team as well as providing overall organizational leadership of claims editing and recovery vendors aimed at managing overall healthcare costs)

• Corporate Configuration of the QNXT system for all lines of business, which may also include the Care Management application for UM functions within QNXT:

Meeting state regulatory requirements

Enabling the system to produce expected health care costs

Maximizing MASS Adjudication within QNXT

Improving the quality of the provider payments

Reducing G&A costs as part of the enterprise-wide efforts to meet or exceed budget targets and to consistently reduce G&A

Continuing to drive positive operational and financial outcomes within the other Provider Payment Initiatives

Job Qualifications

REQUIRED EDUCATION:

Bachelor’s Degree or appropriate relevant healthcare experience

REQUIRED EXPERIENCE/KNOWLEDGE, SKILLS & ABILITIES:

• Minimum of 10 years Healthcare experience in related job or Operational experience

• Specific experience and demonstrated success in Payment Integrity, preferably leading content development

• 5 years Managed Care payor experience, preferably Medicare / Medicaid experience

• 5 years of leadership experience at a senior level

• Technical experience / understanding of data systems and edit configuration, such as SQL, Databricks, etc.

• Strong strategic thinking with ability to translate strategy into operational goals, excellent collaboration, financial, analytical, and change management skills strongly preferred

• Strategic and growth mindset and proven strategy skills in building consensus and alignment with executive stakeholders.

• Excellent verbal and written communication skills

• Excellent organizational and people management skills

• Ability to influence and drive change among peers and others within the Molina organization

• Skill to envision, craft proposals, obtain consensus around approving and implementing future payment ideation initiatives and systems needed to support strategic direction set by organization.

• Maintain confidentiality and comply with Health Insurance Portability and Accountability Act (HIPAA)

• Ability to establish and maintain positive and effective work relationships with coworkers, clients, members, providers, and customers.

• Travels to worksite and other locations as necessary (limited basis)

PREFERRED EDUCATION:

Master’s Degree

To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing.

Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.

Pay Range: $186,201.39 – $363,092.71 / ANNUAL

Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.